Flexible training provides an extremely valuable opportunity for doctors - male or female - who in the face of external pressures wish to continue practising medicine. The most important determinants of career choice among both male and female medical students in an Australian survey,1 seemed to be “the opportunity for part time training, flexible working hours and part time practice.” These factors were more important to women than to men.

Our study examines the attitudes and awareness of medical students towards flexible training opportunities. We distributed a questionnaire to students in the first, third, and fifth years at Birmingham medical school during May and June 1996. Data from the questionnaires were analysed with two computer packages: EpiInfo, and Stats View.

Results and discussion

The overall response rate was 61% (328/540). The response rate was 58% (145/249) for men and 63% (183/291) for women. For first year students it was 57% (107/189), third year students 57% (94/166), and fifth year students 73% (121/166). Analysis showed that there were no significant differences between men and women or between the years with regard to ethnic group, age, marital status, and parity.

Summary points

95% of medical students considered flexible training a good idea

76% of medical students (96% of women and 51% of men) would consider undertaking flexible training in the future

Of the 24% of students who would not consider flexible training, 81% thought it a good idea

The reason most commonly given for considering flexible training was “family commitments.” “Maintaining interests outside medicine” and “future unforeseen circumstances” were also commonly given

46% of students had not heard of flexible training before - of whom 77% would consider flexible training

In all, 54% of students in our study were aware of flexible training before reading our questionnaire. Awareness of flexible training increased with year of medical school - 11% (12/107) of first year students, 48% (45/94) of third year students, and 97% (117/121) of fifth year students had heard of flexible training.

Most of those who had heard of flexible training, both men and women, were aware that flexible training was available to both sexes. 79% of fifth year students had heard of flexible training at a careersõ fair or a house officersõ training day that had taken place during their final year. The next most significant sources of awareness of flexible training were doctors and colleagues (31% of students). Unsurprisingly, senior students were more likely to have heard from doctors and colleagues than those in their first year.

Students in each year tended to have heard of flexible training in that year of medical school, either from our questionnaire or before; 80% were satisfied that they had heard at that time. Of those students who were unsatisfied with when they had heard of flexible training, 51% wanted to hear before medical school, some of whom suggested that the prospectus would be an ideal choice for publicity and may provide the opportunity for more candidates to consider medicine.

The table shows the studentsõ responses when asked if they would consider flexible training in the future. Altogether, 76% of students expressed an interest (that is, said yes or maybe); 95% of women expressed an interest, and 51% of men also did so. Interest in undertaking a flexible training post increased with year of medical schoolDas did the proportion saying that they would not consider it. Final year students were more definite in their replies than the lower years, perhaps reflecting clearer ideas on future plans. Final year students have had more time to contemplate their decisions.

Numbers (percentages) of students who saw flexible training as a future option

The large majority of students 95% (311/328) considered flexible training to be a good idea (99% (181/183) of women and 90% (130/145) of men). Despite the fact that 80 students said that they would not consider flexible training, 81% of these students did say that they thought it was a good idea. It seems that these students were not only thinking of themselves but liked the idea of flexible training being available for others. Given that some senior medical staff, particularly men, perceive flexible training as an inferior option,4 it is encouraging to find that these students, who may well be involved in the supply of flexible training posts, understand its benefits.

With open ended questions students were asked to qualify their positive or negative attitudes towards flexible training. Family commitments was the most commonly given reason for a positive attitude (52% (128/248) of students who expressed an interest in flexible training; 66% (115/174) of women compared with 18% (13/74) of men). Perhaps this 18% of men reflects the fact that “men are now taking a greater part in family life and supervision.”1 Fifth year students were more likely than first or third year students to give this reason to consider flexible training, perhaps reflecting that they are closer to contemplating starting a family.

In all, 77 students felt that flexible training could serve to maintain other interests outside medicine. From the first to the fifth year increasing proportions of students mentioned this, suggesting that as students progress through medical school they become increasingly aware of the need for a release from medicine. The prospect of unforeseen circumstances arising in the future was the third most common reason given (by 31 students) for a positive attitude towards flexible training. Men were more likely than women to mention this, perhaps because women were more specifically concerned with future family commitments. Other students gave more detailed replies: 13 mentioned caring for a dependent relative, and 12 the possibility of future personal illness or disability.

Twenty students wrote “less hours” when verifying their positive response. Such an unqualified comment is difficult to analyse, but it is notable that this was a less frequent response than the three reasons already given Three of the students explained that they were simply lazy.

Six students said that they thought that flexible training would serve to minimise the stress related to a medical career. From issues already raised, it seems that many students acknowledge their career path is demanding and consider it important to maintain interests outside medicine to ease the personal pressure when other areas of their life become important.

Eleven students thought that flexible training would allow time for medical research; 32 students mentioned that flexible training would serve to prevent the unnecessary loss of doctors from the medical profession - reflecting one of the key aims of the flexible training scheme,5 indicating that it is well directed.

There are, however, issues about flexible training that some students felt were important points for concern. The main reason for doubt given by 22 students (16 men and 3 women) was that too long would be spent in the training grades, or training would not be completed. Our results suggest that women are probably more likely than men to accept a longer training to balance a family and career. Earning less money was given by five students as a reason not to consider flexible training. However, few doctors who train flexibly do so for any length of time. Thus flexible training does not double their length of training - it merely facilitates an individual to con- tinue practising medicine in the face of external pressures.3

Sixteen students expressed concern that consultants may be prejudiced against a doctor who has worked flexibly. Issues of diminished continuity of care, lack of experience, and lack of dedication to medicine were also raised by a few students. However, the revised flexible training scheme should ensure both that such schemes are comparable with full time training and that balance is maintained between flexible arrangements and patientsõ needs. A few students considered flexible training as an inferior soft training option, only for women or not necessary in their chosen career.

Students also raised the issue of the need for more information on career opportunities, including flexible training during medical school. In all, 77% of students who had not heard of flexible training expressed an interest in it. More than 50% of medical students today are women - it is important that they should know of an option that can help them to combine a family life with their future career ambitions.

Full time backlash?

EDITOR

The article by Helen Gibson relating to part time doctors is biased and mostly baseless.1 I suggest that political correctness is promoting editors like you to accept and publicise these views. Why not ask someone else (other than a part timer) to comment? I will do. I am a full time consultant general physician, father, husband, son and brother, friend, and family member. I have been a college tutor and assistant clinical director for 5 years, was chairman of the audit committee and do a bit of private practice. I even manage to publish every year or so and keep myself near the front of personal and departmental computing most of the time.

I have been the editor and vice president of my school old boys association for 4 years and organiser of my batch reunion. I play badminton and bridge every week, watch films regularly and do not miss social functions. I visit my parents in Australia every other year and teach science to my daughter and two friends for an hour every working day. And I am simply an average full time consultant on a one in six acute rota.

Part timers do not bring anything other than uncertainty to medicine - they are the ones who get reduced stress and greater fulfilment as they hide from patient needs. Even with guidelines and evidence based medicine there is a personal element in medicine; I have patients who would like to be reviewed by the same doctor (me or my colleague) in the clinic even if they can be seen by the other consultant. I get calls from GPs which can be responded to only if you know the patient, and really canõt wait. Continuity is medicine. Put yourself in a patientõs positionõwould you like to be seen by different doctors for the same problem (assuming average competence of the doctor)?

Part timers are no good for any medical specialty where there may be a need for quick action not because they are not good, but because they regularly become unavailable - other part timers who may be “working elsewhere for remuneration” are different because they are always available. What patients and GPs do not want is one way communication.

To suggest that part timers develop special wisdom in the few hours that they become unavailable is rubbish. Even a full time worker works only about 50 hours a week out of 168 hours and I cannot see how tending to your grandmother or baby for 15 of those hours makes one a better doctor. It may be that part timers are tired, stressed, and unfulfilled because they are having to catch up with developments, having delegated communication to someone else in his or her absence, making communication a problem. Recommending change is fashionable these days, even if there is no evidence for the efficacy of a new system. Team working is another fashionable term but how does a team work when you are not there?

As a hospital doctor my comments may not be applicable universally, but though I believe that part time doctors can be as good or even better doctors than the full timers, they are undoubtedly worse for their patients. They are like sophisticated automated telephone answering systems to which we often hang on hoping to hear a human word, ideally from a recognisable voice!